Complex Cases: Order of Operations

The management of young and active patients presenting with concomitant cartilage lesions, meniscal deficiency, ligamentous insufficiency, and limb malalignment can pose a challenge for orthopedic surgeons. Coexisting injuries alter the homeostasis of the intra-articular environment and joint biomechanics, leading to degenerative changes and ultimately secondary osteoarthritis. In these patients, joint-preserving procedures offer the opportunity to restore function and improve outcomes while delaying the development of osteoarthritis. Each patient will have a unique presentation, thus requiring an individualized approach. A thorough assessment is crucial, including the evaluation of lower limb alignment, which is critical to a positive postoperative outcome. Surgical management should be tailored to the patient, their injury pattern, and pathology. Advancements in joint preservation techniques create the opportunity to address these issues simultaneously through concomitant procedures. While the current literature provides some evidence-based recommendations for approaching these complex joint preservation cases, there is no consensus on the optimal approach for surgical management of combined pathologies. Each case is unique, and surgeons must draw upon their surgical experience and shared decision-making with patients. The patient should be counseled regarding the risk of surgery, the risk of undergoing combined surgery, and the expectations for rehabilitation and return to activity following surgery.